Incorporating a Client Perspective
into the Design of Services
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JHPIEGO is to be applauded for realizing the importance of working with
key stakeholders while developing and implementing quality services. For example, the
Strategy Paper says, "Sharing the results of the needs assessment is an important
part of the advocacy work because it sensitizes key stakeholders to relevant issues and
proposed solutions and provides an opportunity to solicit their feedback" and
"To be successful, government officials and other stakeholders, such as medical
specialists and educators, must be committed to the concept of PAC" (Ghosh, Lu and
McIntosh 1999). A bit later the paper says, "Once support has been received, these
stakeholders can serve as spokespersons for the project and become advocates for raising
awareness of the need to provide quality care to women suffering from complications of
incomplete abortion " (Ghosh, Lu and McIntosh 1999). All this is absolutely
necessary. And I would add another important stakeholder who needs to be consulted: the
client, the community. At the same time we improve services, we need to be working with
the community to ensure that the clients’ perspective of what determines quality is
taken into account in developing and implementing PAC. "The community should be
consulted not only on the nature of the problem, but on the solution as well" (Maine
1997). To achieve quality services which fill clients’ needs, health providers need
to engage in a dialogue with clients. At the beginning of the PMM project in Accra,
Ghana, the team conducted focus groups in rural communities. They learned that
transportation was a problem for women with obstetric complications, so they created a
maternity waiting home near the district hospital. The maternity waiting home is a place
near a hospital with emergency obstetric services. When labor begins, women at higher risk
of obstetric complications can easily be transferred from the waiting home to the
hospital. But people didn’t use the waiting home. In later focus groups, community
members cited a number of features of the waiting home to explain the poor utilization of
the home. Some of these could have been avoided or solved by prior consultation with the
communities. It is possible, however, that maternity waiting homes might never have been
attempted in Ghana if the community had been consulted (Maine 1997; Wilson et al 1997).
Many private voluntary organizations (PVOs) are now using rapid appraisal methods or
other qualitative methods to improve their understanding of the client perspective. For
example, PVOs in Zambia are using these methods to develop adolescent RH services.
MotherCare has conducted very interesting formative research on induced abortions in
Pakistan. Training of service providers for counseling will be more appropriate if based
on such qualitative research. |
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Community Organizations as
Partners—JHPIEGO: A Community-Oriented Organization?
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JHPIEGO is not a community-based organization; its strengths lie in
training, service delivery, and policies and guidelines. How can JHPIEGO take the
client’s perspective into account in designing services? How can it address the many
constraints to access, demand and quality of service? JHPIEGO has taken the first step
already by including in the new maternal and neonatal health (MNH) Program the Centre for
Development and Population Activities (CEDPA) and JHU/PCS, organizations with considerable
experience in advocating and dialoguing with communities.
In an important second step, JHPIEGO should collaborate with these partners to create
and work with networks of organizations that can:
help remove constraints,
help incorporate the clients’ view into the design and
implementation of services, and
conduct the advocacy mentioned in the draft paper.
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The Nepal Example
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In the few remaining minutes, I would like to focus on the Nepal Safe
Motherhood Network. This Network comprises over 70 NGOs, international nongovernmental
organizations (INGOs), donor agencies, professional organizations and private firms
working hand in hand with the Government of Nepal to achieve the Network’s goal to
"improve the status of women by contributing to safe motherhood through advocacy and
awareness creation" (Leavitt et al 1997; Putney 1999). I believe that a similar
kind of network could be formed around postabortion issues and could be used to mobilize
support for PAC at the national, regional, local and village level. It should be
emphasized that this is a promising method which needs to be evaluated.
By 1996, the Government of Nepal had approved a National Safe Motherhood Policy and
Plan of Action, National Maternity Care Guidelines had been published, IEC materials had
been developed and printed, and Clean Home Delivery Kits were being mass-produced by a
local nonprofit NGO for purchase by families at an accessible price. Despite these
accomplishments, there was a growing sense of frustration within the government and
development community that the Safe Motherhood Program had yet to be effectively launched.
Between October 1995 and May 1997, four major events to create grassroots awareness
that were supported by workshops, the press and other mass media succeeded in
disseminating information to millions of Nepalese and created a grass roots movement on
RH. The sequence of events is as follows. |
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National Condom
Day: The Model Event in October 1995 |
The idea behind National Condom Day was to use low cost, entertaining,
local events following an important national holiday to educate men and women about the
need to use condoms for both disease prevention and family spacing. The nationwide event,
sponsored by CEDPA/Nepal, the Nepal Red Cross Society, and 26 other NGOs/INGOs, with the
support of the MOH, involved mass rallies of men and women who participated in events such
as condom blowing contests, games, street dramas and puppet shows. |
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National Clean
Delivery Day, 1996 |
The Nepal Save the Children Alliance and MCH Products, Pvt. Ltd. (the NGO
that manufactures the Clean Home Delivery Kit), asked the organizers of Condom Day to
produce a similar event to promote Safer Motherhood in celebration of International
Women’s Day. The theme chosen for the first Safe Motherhood event was
"National Clean Delivery Day." Supported by the MOH’s Family Health
Division, a coalition of 26 NGOs/INGOs mobilized their field staff and a network of
volunteers to organize programs to promote "Clean Delivery" at the village level
in 41 districts around the country. The Prime Minister’s wife, a new mother herself,
was asked to be the event’s Honorary Chairperson. An activity guide was developed and
distributed to enable the organizers of the events to effectively use creative
communication strategies such as street dramas, puppet shows, rallies, exhibits,
discussions and demonstrations of the Clean Home Delivery Kit to promote "clean
delivery" messages. Complimentary posters, stickers, flash cards, Clean Home Delivery
Kits and other promotional materials depicting safe motherhood messages were also
distributed during all the events.
A press packet was developed and distributed, resulting in extensive coverage by
newspapers, radio and television at the national and local levels. The coalition also
placed a full page promotional announcement in the national newspaper. Through the use of
already existing and local materials and volunteers, as well as local NGO/INGO and
government networks, the entire cost of the national event was only US$4,000. |
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Formation of the
Safe Motherhood Network |
The huge success of National Clean Delivery Day in March 1996 inspired the
organizers of the event to form an ongoing network to enable them to work together more
effectively to address the acute problem of maternal and neonatal deaths in Nepal. Succeeding
steps included:
- a planning workshop,
- use of a woman’s festival to promote safe motherhood messages,
- the first annual meeting of the Safe Motherhood Network,
- the Second National Safe Motherhood Day, and
- Understand Safe Motherhood—a national inter-sectoral workshop.
The initial coalition of 26 NGOs, INGOs, donors, governmental agencies and professional
organizations has grown to include 75 official members, not including organizations that
participate in Network activities at the district level.
Initially, most of the Network’s committees were chaired by expatriates, and the
meetings were held in English. As a direct result of the capacity building and leadership
development that have taken place through the Network, today all committees are chaired by
nationals and all meetings are conducted in Nepali. (For an in-depth discussion of how
this network was developed and how it functions today, please see the references cited at
the end of this paper.) |
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Conclusion
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In summary, the methods that I have discussed and that Susan Settergren
will present in the next paper can be used to educate and to mobilize communities. But
more important, they can help JHPIEGO to form a partnership with communities. The Nepal
model has not yet been tested for its effectiveness in increasing utilization of health
services or in changing home care practices. At the same time that we add community
components to our programs, we need to incorporate qualitative and quantitative
evaluations to demonstrate that these approaches really are worth the faith and effort
that we put in them. |
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References
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Ghosh A, ER Lu and N McIntosh. 1999. Establishing Postabortion Care
Services in Low-Resource Settings. Paper prepared for JHPIEGO Postabortion Care
Workshop: Issues in Establishing Postabortion Care Services in Low-Resource Settings,
20–21 May 1999. Draft. Levitt MJ et al. 1997. Getting Messages Out:
Partnerships and Innovative Community Mobilization in Nepal. Paper for presentation at
the 1997 NCIH Conference, Washington, D.C., 12–14 June.
Lo A and L Hoemeke. 1998. Turning Something Old into Something New. The Green
‘Pendulu’ and Maternal Health in Mali. Africare. Unpublished.
Maine D. 1997. Lessons for program design from the PMM Projects. International
Journal of Gynecology and Obstetrics 59(Suppl. 2): S259–S265.
Post M. 1997. Preventing Maternal Mortality through Emergency Obstetric Care.
Support to Analysis and Research in Africa (SARA) Issues Paper. (April).
Putney P. 1999. Working Together to Save the Lives of Nepalese Women and Children: A
Case Study of the Nepal Safe Motherhood Network. Draft.
Wilson JB et al. 1997. The maternity waiting home concept: The Nsawam, Ghana
experience. International Journal of Gynecology and Obstetrics 59 (Suppl. 2):
S165–S172. |
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